Comparisons of insurance compensation in relation to the epidemiological magnitude of occupational diseases are not frequently published despite the importance of this topic in evaluating inequalities and efficiencies of health care and welfare systems. The few published data regard MM because of the generally well known occupational etiology of the disease. For the 499 malignant mesothelioma cases recorded by the French Mesothelioma National Program in the period 1999‐2001, 309 (62%) sought recognition of an occupational disease, and it was granted for nearly all of them (91%). This proportion varies geographically and is closely related to physicians’ sensitivity to the occupational origin of the disease [15
]. In Australia the Central Cancer Registry recorded 3090 malignant mesothelioma cases between 1972 and 2004, and the Dust Diseases Board compensated approximately 60% of these in that period [16
]. A detailed analysis for the Canadian province of British Columbia reported 33% of MM cases in the provincial registry linked at the individual level with accepted claims for the period 1970‐2005 [17
]. The critical point of these analyses is the lack of definition of occupational asbestos exposure by the epidemiological surveillance systems.
In Italy the ReNaM has been active since 1993 (compulsory since 2002) with the aims of defining the incidence rates and investigating each subject’s individual occupational, residential and environmental history using a structured questionnaire. Some important limitations regarding the ReNaM dataset bear discussion. The Register has not been developed uniformly throughout the country. This is why the selected period for analysis was 2000‐2004, guaranteeing a large enough sample and adequate territorial incidence coverage. Regions differ in their assessments of asbestos exposure with respect to incident cases, depending on the resources available. While the national guidelines for the standardization of MM cases collected aim to correct this imbalance, there are still large gaps among the different regions. Furthermore this study looked only at incident cases, not incidence rates and the reference populations of ReNaM and of the insurance system are not the same.
The overall rate of compensation for mesothelioma claims in Italy due to occupational exposure to asbestos is 49.7%, and more than 90% of these are granted by the workers’ compensation authority. A substantial number of people who deserve compensation for MM do not seek it. The percentage (50.3%) is higher than in the Canadian survey but no real comparison can be made because that registry does not specify industry sectors and occupational categories.
Compensated cases increased by 38.6% in the period 2000–2004 whereas the increase in the ReNaM occupational caselist was only 11.1% (from 584 in 2000 to 649 in 2004), indicating that epidemiological patterns only partially explain compensation decisions, which are influenced by sensitization and awareness [18
In Italy owners are obliged to insure their workers for injuries and occupational diseases. However, the self-employed have no such obligation. INAIL is the institute with the main role, but some categories such as the military and firemen (jobs involving asbestos exposure) come under other specific insurance systems. Eligibility criteria for compensation include diagnostic certainty and an asbestos exposure suffered in the work place.
The likelihood of an individual with mesothelioma due to occupation seeking and receiving compensation was gender-specific. Mesothelioma is more frequent in men because of the larger proportion of male workers in the industrial sectors “historically” with high asbestos exposure, such as shipbuilding and repair, railway rolling stock maintenance, the asbestos-cement and construction industries. Thus the disease is under-recognized as being of occupational origin in women. The proportion of women with MM who were occupationally exposed and are collected in the Register is 13.3% but only 8.9% of cases received compensation. Probably women need to be better informed about the causes of the disease in view of the absence of a threshold for its occurrence [19
The probability of seeking compensation for MM cases with occupational asbestos exposure declined steeply in relation to age at diagnosis. The ReNaM database indicates that age at diagnosis and diagnostic certainty are correlated. The proportion with a not-definite diagnosis was significantly higher among cases older than 75
years. This might well be because there is a tendency to avoid the use of invasive diagnostic methods in elderly and suffering patients [11
]. Often too, retired people are less aware of an exposure risk in their workplace many years earlier. Clinicians need to become more aware of the need to enquire not only about a patient’s current work status but also about the work history. For occupational tumours, and particularly MM, the long latency (generally around 40
years), the variety of occupations involved in exposure and the absence of a threshold, often make it difficult to identify the correct etiology [20
In the multivariate model, after adjustment for all variables, the region of residence at diagnosis remained a significant source of variation in the probability of not seeking compensation for occupationally exposed patients. This is worth stressing as an opportunity to define policies to reduce this source of inequality. The sensitivity and awareness of health care system operators (clinicians particularly) was far from uniform over the whole country, and the level was particularly low in the south of Italy. There is therefore a pressing need to systematically spread information about the causes of MM and patients’ rights, also using the ReNaM network.
At present only Italy, France [15
] and Australia [21
] have specific epidemiologic surveillance systems for mesothelioma cases based on active searches and individual interviews to analyze the occupational history of each case. Mesothelioma mortality surveillance is based on death certificates in Great Britain [22
] and the United States [4
], and also on territorial cancer registries in the United States [23
] and Germany [24
]. In the Nordic countries the complete development of national cancer incidence registries allows systematic linkage with occupational information archives [25
Analyses to verify the extent of compensation for MM cases by economic sector of exposure are not frequently published. The highest rates of compensated cases are after occupational exposure in activities known to involve asbestos. Heavy asbestos exposure during the maintenance and disposal of insulation from railway carriages is often reported in Italy [28
] and elsewhere [21
]. The asbestos-cement industry [33
] and shipbuilding and repair [35
] provide the most detailed published studies on account of the number of plants involved and exposed workers in Italy. Our findings confirm that workers in these sectors and clinicians are well informed about the occupational origin of the disease. In contrast, where the worker has been exposed to asbestos during work but this was not evident, the probability of seeking (and receiving) compensation is much smaller. The MM cases due to exposure in the education sector, like in the social and health care services, provide evidence of this.
At present the most important area of exposure for MM cases collected by the Italian surveillance program is the construction industry, where asbestos has been used for fireproofing and acoustic insulation, in mixtures with cement and plastic and in vinyl flooring. As a result, construction workers could be involved in the risk of asbestos exposure during maintenance and restructuring activities [36
]. The circumstances of asbestos exposure in the construction sector are generally not evident and not easy to define correctly, especially when no direct interview with the person concerned is available. A large proportion of MM cases exposed during work in this sector do not apply for compensation. Almost all construction workers are men, and in the adjusted analyses their relative risk was significantly elevated.
Our data highlight the importance of the documentation and dissemination of all asbestos exposure modalities since many - considering the large-scale use of asbestos and the absence of a threshold for the dose–response curve - are frequently not expected. Regulatory and public health agencies need effective notification systems to ensure that all individuals newly diagnosed with MM seek compensation benefits.